Endodontic Treatment Financial Policy & Agreement

Patient Information

Name: ___________________________ Date: _______________ Date of Birth: ____________________ Account #: ___________

Financial Policy

Payment Responsibility

1. Payment is due at the time of service unless prior arrangements have been made
2. We accept cash, personal checks, and major credit cards (Visa, MasterCard, American Express)
3. For patients with insurance, we will submit claims as a courtesy, but the patient remains responsible for any unpaid balance

Insurance Information

• We participate with many insurance plans but cannot guarantee coverage
• Patient is responsible for knowing their insurance benefits and limitations
• Deductibles and co-payments are due at the time of service
• Pre-authorization is not a guarantee of payment

Treatment Fees

Initial consultation and diagnostic testing: $______ Root canal treatment (per tooth): $______ Post and core (if needed): $______

Payment Plans

• CareCredit® financing available for qualified patients
• In-house payment plans available upon approval
• 5% courtesy discount for payment in full at time of service

Cancellation Policy

• 48-hour notice required for appointment cancellation
• $75 fee may apply for late cancellations or missed appointments

Agreement

I have read and understand the financial policy above. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law or the treating dentist has a contractual agreement with my plan prohibiting all or a portion of such charges.

Signature: _________________________ Date: _______________

Office Use Only

Staff Initial: _______ Date Received: _______